MEDICARE: DAWN MARIE WILDERMUTH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	S1872	OTHER	FL	BC/BS

General Provider Information

NPI Number	:	1235331075
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAWN MARIE WILDERMUTH

Provider Business Mailing Address
First Line	:	411 COMMERCIAL CT
Second Line	:	STE F
City	:	VENICE
State	:	FL
Zip	:	34292-1650
Country	:	US
Telephone Number	:	941-468-6701
Fax Number	:	941-485-0519

Provider Business Practice Location Address
First Line	:	411 COMMERCIAL CT
Second Line	:	STE F
City	:	VENICE
State	:	FL
Zip	:	34292-1650
Country	:	US
Telephone Number	:	941-468-6701
Fax Number	:	941-485-0519

Authorized Official
Title or Position	:	OWNER
Name	:	DAWN WILDERMUTH
Credential	:	MS CCC/SLP
Telephone Number	:	941-468-6701

Provider Enumeration Date	:	06/04/2007
Last Update Date	:	07/04/2008

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